创伤和外科重症护理的文档和编码:更新和提示。

IF 2.1 Q3 CRITICAL CARE MEDICINE
Trauma Surgery & Acute Care Open Pub Date : 2024-10-16 eCollection Date: 2024-01-01 DOI:10.1136/tsaco-2024-001532
Jordan Michael Kirsch, Samir M Fakhry, Andrew Bernard, Gail T Tominaga
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引用次数: 0

摘要

临床记录是医疗实践的重要组成部分。医疗记录是医疗服务的持久见证,也是医疗服务提供者之间沟通的基础。医疗记录为医疗服务提供者和医院的医疗编码和计费提供理由和支持,也为监管和法律程序提供证据。在此,作者强调了临床文件在支持专业和医院计费方面的重要性,并讨论了近期监管变化的两个领域:疝气手术的手术编码和重症监护的专业编码。作者还讨论了医疗服务提供者的文档在支持组织收入和质量方面的重要作用。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
Documentation and coding for trauma and surgical critical care: updates and tips.

Clinical documentation is an essential part of medical practice. Medical records serve as a durable testament of care provided and are fundamental to communication among providers. Medical records provide justification and support for healthcare coding and billing for providers and hospitals and also provide evidence in regulatory and legal proceedings. Here, the authors emphasize the importance of clinical documentation in support of both professional and hospital billing and address two areas of recent regulatory changes: Operative coding for hernia operation and professional coding for critical care. The important role of provider documentation in supporting organizational revenue and quality is also discussed.

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来源期刊
CiteScore
3.70
自引率
5.00%
发文量
71
审稿时长
12 weeks
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